CC BY-NC-ND 4.0 · Indian J Radiol Imaging 2024; 34(02): 232-238
DOI: 10.1055/s-0043-1776340
Original Article

Role of Pancreatic Attenuation Index in Assessing Pancreatic Fat Content and Postpancreatectomy Outcomes

Rizwan Ahmed Perikinchira
1   Department of Surgical Gastroenterology, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
1   Department of Surgical Gastroenterology, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
Bonny Natesan P.
1   Department of Surgical Gastroenterology, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
Bindiya Gisuthan
2   Department of Pathology, Trivandrum Medical college, Thiruvananthapuram, Kerala, India
L. Jayasree
3   Department of Radiology, Trivandrum Medical college, Thiruvananthapuram, Kerala, India
Swasthik K.S
1   Department of Surgical Gastroenterology, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
Santhoshkumar Subramanian
1   Department of Surgical Gastroenterology, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
Agestino V. Antony
1   Department of Surgical Gastroenterology, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
› Author Affiliations


Background High fat content of pancreas can contribute to its soft texture, which is a strong predictor for postoperative pancreatic fistula (POPF). We propose to assess the relationship of pancreatic computed tomography (CT) attenuation index (PAI) with histopathological fat content of pancreas and postpancreatectomy outcomes.

Methodology Data was collected prospectively from patients who underwent pancreatic resections from February 2021 to January 2023. CT attenuation was measured in pancreas and spleen in three regions of interest each. The mean of the three values was taken as the mean pancreatic attenuation (P) and splenic attenuation(S). PAI was calculated (P-S and P/S) preoperatively. The fat content was calculated histologically in resected specimens. The pancreatic texture was also assessed intraoperatively by the operating surgeon to classify it as soft or firm. The relationship of PAI with fat content and postpancreatectomy outcomes such as delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH) and POPF was assessed.

Results Seventy patients underwent pancreatic resections of which 59 were taken for analysis after satisfying the exclusion criteria. The PAI ranged from P-S (-23 to +19) and P/S (0.54–1.5). The histologic fat content of pancreas ranged from 0.4 to 42% (mean= 9.5076/standard deviation: 9.19520). Significant correlation was found between P-S and P/S (Spearman's rank correlation coefficient ρ = –0.775[95% confidence interval [CI]: –0.919 to –0.583], –0.743[95% CI: –0.896 to –0.467]) with pancreatic fat content. Postpancreatectomy outcomes noted were POPF(B/C):13, DGE:33, and PPH:3. Statistical significance was not seen between PAI and postpancreatectomy outcomes (POPF, p = 0.067 DGE; p = 0.456; PPH, p = 0.891).

Conclusion PAI may be used as a reliable tool in predicting pancreatic fat content. However, it did not show a statistically significant association in predicting postpancreatectomy outcomes.

Publication History

Article published online:
20 November 2023

© 2023. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

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  • References

  • 1 Ahirwar R, Mondal PR. Prevalence of obesity in India: a systematic review. Diabetes Metab Syndr 2019;13(1): Accessed October 11, 2023 at:
  • 2 Majumder S, Philip NA, Takahashi N, Levy MJ, Singh VP, Chari ST. Fatty pancreas: should we be concerned?. Pancreas 2017; 46 (10) 1251-1258
  • 3 Ho CK, Kleeff J, Friess H, Büchler MW. Complications of pancreatic surgery. HPB (Oxford) 2005; 7 (02) 99-108
  • 4 Kusafuka T, Kato H, Iizawa Y. et al. Pancreas-visceral fat CT value ratio and serrated pancreatic contour are strong predictors of postoperative pancreatic fistula after pancreaticojejunostomy. BMC Surg 2020; 20 (01) 129
  • 5 Hashimoto Y, Traverso LW. Incidence of pancreatic anastomotic failure and delayed gastric emptying after pancreatoduodenectomy in 507 consecutive patients: use of a web-based calculator to improve homogeneity of definition. Surgery 2010; 147 (04) 503-515
  • 6 El Nakeeb A, Salah T, Sultan A. et al. Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience). World J Surg 2013; 37 (06) 1405-1418
  • 7 Ansorge C, Strömmer L, Andrén-Sandberg Å, Lundell L, Herrington MK, Segersvärd R. Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy. Br J Surg 2012; 99 (08) 1076-1082
  • 8 Hu BY, Wan T, Zhang WZ, Dong JH. Risk factors for postoperative pancreatic fistula: analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol 2016; 22 (34) 7797-7805
  • 9 Kim SY, Kim H, Cho JY. et al. Quantitative assessment of pancreatic fat by using unenhanced CT: pathologic correlation and clinical implications. Radiology 2014; 271 (01) 104-112
  • 10 Wente MN, Bassi C, Dervenis C. et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142 (05) 761-768
  • 11 Wente MN, Veit JA, Bassi C. et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142 (01) 20-25
  • 12 Bassi C, Marchegiani G, Dervenis C. et al; International Study Group on Pancreatic Surgery (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017; 161 (03) 584-591
  • 13 Clavien PA, Barkun J, de Oliveira ML. et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009; 250 (02) 187-196
  • 14 Gnanasekaran S, Durgesh S, Gurram R. et al. Do preoperative pancreatic computed tomography attenuation index and enhancement ratio predict pancreatic fistula after pancreaticoduodenectomy?. World J Radiol 2022; 14 (06) 165-176
  • 15 Ohgi K, Okamura Y, Sugiura T. et al. Pancreatic attenuation on computed tomography predicts pancreatic fistula after pancreaticoduodenectomy. HPB (Oxford) 2020; 22 (01) 67-74
  • 16 Sushma N, Gupta P, Kumar H. et al. Role of ultrasound shear wave elastography in preoperative prediction of pancreatic fistula after pancreaticoduodenectomy. Pancreatology 2020; 20 (08) 1764-1769
  • 17 Kalayarasan R, Himaja M, Ramesh A, Kokila K. Radiological parameters to predict pancreatic texture: current evidence and future perspectives. World J Radiol 2023; 15 (06) 170-181
  • 18 Zhou L, Xiao WM, Li CP, Gao YW, Gong WJ, Lu GT. Impact of fatty pancreas on postoperative pancreatic fistulae: a meta-analysis. Front Oncol 2021; 11: 622282
  • 19 Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer Jr CM. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 2013; 216 (01) 1-14
  • 20 Heeger K, Falconi M, Partelli S. et al. Increased rate of clinically relevant pancreatic fistula after deep enucleation of small pancreatic tumors. Langenbecks Arch Surg 2014; 399 (03) 315-321
  • 21 Iacono C, Verlato G, Ruzzenente A. et al. Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy. Br J Surg 2013; 100 (07) 873-885
  • 22 Kanwat S, Singh H, Sharma AK. et al. Pancreatic dysfunction and reduction in quality of life is common after pancreaticoduodenectomy. Dig Dis Sci 2023; 68 (07) 3167-3173
  • 23 Barton JG. Enhanced recovery pathways in pancreatic surgery. Surg Clin North Am 2016; 96 (06) 1301-1312
  • 24 Nahm CB, Connor SJ, Samra JS, Mittal A. Postoperative pancreatic fistula: a review of traditional and emerging concepts. Clin Exp Gastroenterol 2018; 11: 105-118
  • 25 Kuan LL, Dennison AR, Garcea G. Outcomes of peri-operative glucocorticosteroid use in major pancreatic resections: a systematic review. HPB (Oxford) 2021; 23 (12) 1789-1798